Dr. Heuser of the Phoenix
Heart Center serves as Chief of Cardiology at
St. Luke’s Hospital and Medical Center in Phoenix,
Arizona. Dr. Heuser is
an internationally-recognized cardiologist, inventor, educator
and author, and one of
the early pioneers of angioplasty. A diplomate
of the American Board of Cardiovascular Diseases and American
Board of Interventional Cardiology, he has more than 30 years
of private practice, medical administration and clinical
teaching experience.

With 13 patents granted for different
catheters, stents and other medical devices, and several
more patents pending, Dr. Heuser has served as principal
investigator to research the safety and/or effectiveness
of more than 100 medical devices and more than 70 pharmaceutical
products. In addition to participating in the more than
150 research studies, Dr. Heuser has authored more than 400
articles,
textbooks and medical manuscripts.

Q: You’ve
been involved in interventional cardiology since the early days
of balloons and stents. Now, as part
of your general cardiology course, you are conducting a
day-long session about the transradial wrist approach.
Dr. Heuser: Right – the first two days, it's a general cardiology
course; on the third day, it's an all-day radial course. So, people
can go to all three days of the course, or they can just do the radial
course. We have some of the top interventional people, but also people
who are leaders in anti-arrhythmic therapy, leaders in heart failure
therapy -- we've got probably the world's top heart failure doctor,
William Abraham, there. In the radial course, we have Ian Gilchrist,
Tift Mann, who are household names in radial circles. I think it's
going to be a lot of fun, so I'd say that the interventional cardiologists,
the general cardiologists, the cardiologist that maybe just does
diagnostic tests, diagnostic heart caths, all would benefit, as well
as nurses and primary care physicians who want a sort of a lay of
the land of what's going on in cardiology.

St. Luke's
Hospital, Phoenix, Arizona

Q: What was your motivation
to add the transradial component?
Dr. Heuser: The transradial
approach is so relevant to patients, as well as to cardiologists
and interventional cardiologists, in terms of being a better
way to treat, to do something that we do millions of around the
world, and that's heart catheterizations. When I first started
doing heart caths in my training in the seventies, I did a lot
of Sones procedures, but that pretty much has fallen down, because
of the incision and so forth. I started doing transradial procedures
around â93 or â94, but the equipment was not great. Now that
the equipment has really gotten a lot better -- the last four
or five years-- and the data is pretty convincing, from not just
RIVAL but other studies, we have switched over to radial access
completely in the last year and a half. And we're pretty evangelistic
about it: we really want to train physicians, so that not just
our patients but other patients have the advantage of this lower-risk
procedure.

Q: You started early on utilizing the
Sones technique, which is a semi-surgical incision or “cut-down” that uses the
brachial artery in the elbow. This is certainly more complicated
and requires more skill than the femoral technique. Why didn’t
you just go femoral?
Dr. Heuser: Between 1990 and 1994 or so, this was at a time where
we were just putting together the criteria in terms of utility of
coronary stents, and we used much more aggressive anti-coagulation
than we do now. We were using pretty primitive treatment regimens,
including heparin and Coumadin. We didn't use Plavix, we used Persantin
and we used Dextran, all of these drugs which we just don't use anymore,
but we still had an incidence of about 6% of subacute stent thrombosis,
ridiculously high. So we actually started bringing patients in fully
anticoagulated and doing the procedures with the Sones technique.
And we could send the patients home the same day. It was okay, but
it’s obviously a lot easier to do this percutaneously, radially.

So, the reason I got started doing radial
procedures is that I also see a lot of patients with peripheral
vascular disease, and at the
same time in the early nineties, I was seeing a lot of patients with
occlusion of their aorta. What I would do many times, rather than
going in from the groin where I couldn't get access, or doing a Sones
where, if I cut down, there was nothing I could do after the angiogram,
I felt the best way to infuse thrombolytics at the time was to do
it using the radial artery in the wrist. So we were using some 4F
catheters that were clearly not meant to be used radially, but they
worked okay in order to get access, and at the same time, we shot
some coronary angiograms from there. But the catheters at that time
were just “Not Ready for Prime Time”, so to speak.

Q: You mentioned that in the last four or five years radial equipment
has gotten better. In what ways?
Dr. Heuser: I think that it's not so much the French size as it is
the way they're tapered, and there are a number of companies that
have really sort of gotten it, sort of taking up the gauntlet to
try to improve the tapering of the catheters and equipment, not just
the profile. You can have a very low profile catheter, but if it's
too stiff, you're not going to be able to get around the subclavian
easily, and you possibly could traumatize the subclavian, which for
a procedure that should be a lot safer than femoral, you don't want.
So we've really been really happy, and it's rare that we have to
switch from the radial to the femoral, certainly less than 1%.

Q: Although the transradial approach has been gaining in popularity
in the past few years, there are still cardiologists out there who
still don't want to even think about it or hear about it. What would
you have to say to the many interventionalists who are femoralists
only, and don't even want to consider the radial approach at this
point?
Dr. Heuser: It's funny -- I train fellows here, and it's simpler
with young doctors, and not for the same reasons you would think.
It's all about doing an arterial line or an arterial blood-gas and,
if you're close to being an intern or resident, you do those a lot
on patients and, if you remember what you do to get access -- I mean
90% of it is access, and then with the equipment, it's really pretty
simple. If you're comfortable with the access, getting into the artery,
and then placing the sheath, the movements in the shafts are very
similar to the Judkins technique and, as a lot of people say, the
trick is, it’s 90% psychological -- you get in with the arm
extended and then once you get access and you get down to the descending
aorta, then you put that arm right to the side, then all of a sudden,
just think that you're going Judkins.

Q: That's what a lot of people have said: it's really not that different
once you've gained access. And also in some cases you're able to
use fewer catheters, because you can go from right to left with the
same one.
Dr. Heuser: Burt, you're exactly right. The catheters that we use,
tend to be universal catheters, the Jacky catheters, the Sarah catheters
made by Terumo. We can easily go in the right coronary, easily go
to the left coronary, and then even do the ventriculogram with one
catheter, and if you compare that to Judkins, where other portions
of the groin technique may go faster, this part's a lot faster with
radial. So time-wise, it's easily the same amount of time or even
less with a skilled radialist.

Q: The uptake of radial in this country has been much slower than
in places like India and Japan and Europe, especially France. Why
is that and what can be done to improve that?
Dr. Heuser: I think the reason that hasn't happened here so much
is that we've got a lot more interventionalists that they do in their
countries, and so each interventionalist does less numbers than say,
in Europe or in Japan or in India, and I think that's the nature
of the beast. On the other hand, it's more competitive here, and
so you've gotta have a better product, and you have to have a safer
product, and a product that patients are happier with. And I can
tell you, there are many things we say in interventional cardiology
to patients, we’ll say, "Well this'll be easy, it's under
local anesthesia, you'll go home a couple hours later," and
then there's the radial procedure, which is pretty much as we say
it, and it really is. The patients will come out and you'll see them
at the end of the procedure or a couple days later, and they really
remark, "Boy, that was a lot easier…that's the only way
to do it."

Q: Speaking of the patients, you've
had a lot of experiences with patients who have had both femoral
and
radial, and that's been their
experience. But why should someone who has been doing nothing but
femorals and, to their knowledge, doing a very good job…why
should they learn the radial technique?
Dr. Heuser: Well, you'll reduce your likelihood of vascular complications
by four times, and if you look at the most comprehensive head to
head trial, the RIVAL trial, you'll see that you will not give up
anything in terms of safety and efficacy. You will give up the fact
that you will have more blood transfusions and more vascular complications
going femorally and, if you look at the sites that were high volume
radials, they actually had an improvement in hard outcomes -- that's
MI, and morbidity, and mortality. So I think that if I could be so
bold as to say, you're doing your patients a disservice if you don't
at least consider radial an option in patients... even to the point
that they request it... because the reality is, they are going to
be requesting it.

Q: In this age of
cost cutting and containment, trying to reduce the giant health
care expenditures that we have
in this county, where does radial fit in?
Dr. Heuser: Well, the fact that you don't need such extensive monitoring
afterwards, in terms of the vascular complications, because the vascular
complications are done by the time you get out of the lab. You put
a TR band or any other kind of compression device on and it's very
easily taken care of with a nurse -- a single nurse can take care
of a number of patients, and in the diagnostic study, a patient can
go home an hour or two after the procedure. In an interventional
case, they probably can go home three or four hours afterwards. And
we're doing that more and more in patients where insurance will allow
us to do these patients truly in an outpatient situation.

Q: My understanding is that sometimes insurance can actually penalize
you for doing it as an outpatient procedure?
Dr. Heuser: You are correct, there are some hospital-based fees that
you don't get by doing it that way, but I think in the long run what
you'll gain is basically happy patients, and probably more patients,
and in the long run you'll make up for it in volume.

Q: And the other thing is of course, as the insurance criteria change,
and Medicare etc. starts aligning the payment system with better
outcomes and being able to use less, costs, that may all change as
well.
Dr. Heuser: Yeah. Let's separate the diagnostic study from PCI. And
when you look at the fact that PCI, particularly PCI from the groin,
is going to have a higher incidence of vascular complications, still
fairly low, but still, when you have an incidence of bleeding or
hematoma or prolonged hospitalization, even if it's just for a few
hours, you start doing the math and it adds up fairly quickly, where
you can be a lot more cost effective by doing it radially.

But I think that you're right, and I think
that we are going to be pushed by the Federal authorities in terms
of keeping our costs
down, and more importantly, when we hear statements that patients
who come in with a complication after another procedure, you're not
going to get paid... I mean, I think that's going to basically jump
in the face of physicians, they're going to have to figure out, "How
can I do this safely and more cost effectively?" And the other
thing is that patients are very knowledgeable, they check the internet,
they check, they Google you and they check to see if you're somebody
that does these procedures radially, and I think that's going to
be more important in the future.

Q: Right. And patients can find hospital
and physicians who practice the transradial approach by checking
Angioplasty.Org’s Transradial
Hospital Locator! Thanks for your time and have a
great course.
Dr. Heuser: We will. It’s on September 9-11, 2011 in Las Vegas,
Nevada.

This interview was conducted in August
2011 by Burt Cohen of Angioplasty.Org